Category: Written Blogs

Keeping the customer/patient happy

 

“…owners and managers an no longer rely solely on the relationships they have built with referral sources to grow their practices”

 

Look at the drug companies…they know how to peddle their wares. Once it became mainstream to advertise directly to the consumer we have what is now known as the “opioid epidemic”. If we can advertise directly to the consumer, and give the consumer what they want…business will boom. We have to know what the consumer wants first though. Don’t try to sell them what we have, know what they want and then create the product. We know that patient’s primarily want education first. Give them a taste of the education during a seminar and then tell them that they have to schedule an appointment in order to get the rest of the information. It’s funny. I remember working for Bill Curtis at PT and Spine and he would refer to the magic treatment. In that patients are looking for that magic so that way they can take control of their own issues. If one is the owner, we want to give the patient the magic…but not on the first day. If we got paid for outcomes and not for the patient coming to the clinic, there would be more incentive to help fix the patient at the initial visit and not carry it on for the national average of 8-16 visits for the average orthopedic issue.  

 

“Even five years ago physicians largely dictated our referral patterns…hospital-based clinics and physician-owned practices are aggressively attempting to keep their patients “in-house”.  

 

Everyone in business wants money. THEY WANT YOUR MONEY! There is incentive to keep you going to the same company for every service performed. If you need an MRI, X-ray, PT, sports physical, etc it is very convenient if it is all under one roof. Now, who is making the money? I’m going to make it easy. If your mechanic finishes looking at your car and then says that you need $10,000 dollars worth of work, but he can do it all at once, what are you going to say? What if I say that you need $20,000 worth of work? How high do I have to take that number before you realize that it may not be legitimate needs to continue? The doctors/hospitals that own all of the above “services” may be doing the same thing, but you never see the costs because the insurance “covers” the cost.

 

“We are aware that patients can choose to receive therapy wherever they would like…”

 

Are the patients aware of this? If you go to the doctor and get a referral for therapy (it’s like a referral to any other practitioner), but the referral has the name of a specific clinic on it, does the patient realize that they can still go anywhere? IF YOU ARE A PATIENT AND ARE READING THIS…YOU CAN GO TO ANY THERAPIST THAT YOU WANT TO GO TO! Not all PT’s have the same training or even the same specialty. If you don’t see progress with your therapist after 6 visits, and you are given the words “it just takes time”, find a new therapist. Some things do take time, but hear it from 2-3 different therapists before you actually believe it.  

 

“We are not here to ‘fix’ a patient; we are here to partner with them in their rehab”

 

This is huge. I don’t fix you…I help you fix yourself. I play the role of cheerleader, teacher, listener, advisor, but at no point am I the “fixer”. When I see you for 2 hours per week, there are so many hours throughout the week in which you have to help keep yourself fixed by what you learn in the clinic.  

 

I realize that I can come across as negative with regards to the business of healthcare and unfortunately it is more of a realistic view than either pessimistic or optimistic. I have had discussions with those that audit clinics, researched the Department of Justice website for healthcare fraud, shadowed/worked/observed in unethical clinics and have heard patient stories from their times in other clinics. My view is personal, but real. When I say get a second or third opinion, it’s because you may have to go through that many different clinics before you find one that has your intentions at the forefront.  

 

Excerpts taken from: Stamp K. Happy Customers: How to create a positive patient experience. IMPACT. July 2016:31-32.

 

 

HR 101

“We must recognize that each one of our employees comes to us with a unique personality and a backlog of experiences that will influence the way they work.”
My experience at Sam’s Club plays a large role in my choices as a physical therapist. Sam Walton was still alive during my first years working for the company. There were some major rules that we had to follow as employees of Sam’s Club. The first rule is the 10 foot rule. This means that any time that I come within 10 feet of a Sam’s Club member I must make eye contact an acknowledge that person. It seems so simple to just give a hello, but we all know that customer service is lacking in many companies. Customer service is the reason we are doing what we are doing. Without the customer we have no income. In healthcare, we can substitute the word customer with the word patient. Without the patient I have no income. I need to ensure that that patient is well taken care of, and that starts just by acknowledging that the patient is a person. Other things that I learned from Sam’s Club is that hard work is rewarded. I was given many merit raises during my first three years at the store. In 2003 I was the best employee out of the 200 employees. This is not subjective on my part, but I was awarded with the employee of the year award. At that time I knew I had to quit. This is another thing that I learned about myself while working at Sam’s Club. I have a drive to improve and to consistently and constantly get better. Once I have reached the top of a certain position, then it is time for me to try new things and strive to be the best. 
“… More than 30,000 physical therapy jobs that will go unfilled in 2016, it is difficult to understand why a practice owner wouldn’t make the effort to appropriately care for their therapist.”
It is easier to take care of the good people that you have working for you than to find a good person In the sea of applicants to a business.  
“Daniel Pink, In his wonderful book, Drive: the surprising truth about what motivates us, point out that people want to believe they are contributing to something meaningful.”
When I worked for Sam’s Club, we had a core group of people that we would go to bat for. We worked hard in order to make up for any shortcomings of the people that were around us. When everybody is pulling in the same direction, great things can be done. I believe that. At the time I worked at Sam’s Club we were doing great things. I currently work with a group of people at small community-based hospital in which we all have our niches. We are all really good at our specific specialties and it is fun to be a part of this team. We don’t have the newest equipment, but we are all share a passion for patient care. It is demonstrated in both our outcomes and our patient satisfaction. We are playing our part in the changes that are occurring in healthcare, which emphasize patient outcomes and improving overall health status.
“Creating strong company values, and a clear mission statement, are necessary to motivate and engage staff. Period. More than 70% of all employees were disengaged at work. Disengaged employees tend to create drama… And subtly communicate their unhappiness to patients.”
This correlates with the old saying idle time will provide for the devils handiwork. If we have something to do and are passionate about doing that activity, we will provide customer service. We have to be engaged more with our patients van with our cell phones or Facebook. 
” Pink suggest that most people are innately motivated by autonomy. Essentially his philosophy is that we should hire good people and let them do their job.”
I love this quote! The problem though is that not all companies hire good people. When you surround yourself with people who are going the extra mile, they push you to go the extra mile. I would much rather play on a team with scrappers, then play on a team with a bunch of superstars. My job is to make my teammate better in their job is to make me better, in the end the patients get better because of the team.
“Too often we repetitively train, and retrain, an employee who is falling short rather than letting them go in order to preserve the overall atmosphere within the clinic. As difficult as it is to terminate an employee, we must put the needs of the whole clinic above the negative behavior of one person.”
This couldn’t be said any more clearer. Politics unfortunately cloud judgment. Legalities cloud judgment. Dave Ramsey has said it many times over if I wouldn’t re-hire that person, then that person should no longer work here.
Excerpts from:

Stamp K. HR 101: The art of managing people. IMPACT. Aug 2016:29-30. 

Core stabilization compared to McKenzie method treatment

 

  1. “The condition has been identified as the leading contributor to ‘years of life lived with disability’ in the world including the United States.”

 

Big surprise, we are talking about back pain again. I see a majority of my schedule as back pain for the previous 8 years. There is no loss of people with back pain. This is an epidemic. The only reason it is not treated in such high regard has cancer, AIDS, Zika, and others is because it’s not deadly and does not cause major deformities. Because back pain is so common, it’s treated with little urgency such as the common cold.

  1. “In Australia, LBP is estimating to reduce gross domestic product by $3.2 billion annually and is the leading cause of early medical retirement for older working people.”

Think about that! You go to school and you load up on student loan debt. After school you get a job paying much less than you think you’re worth. Then you get sidelined by low back pain and are forced to retire well before you’re ready. It doesn’t have to be this way! Not all low back pain is the same, and when you figure out what type of back pain you have it becomes a lot easier to prevent recurrent issues of back pain.

  1. “Directional preference classification is characterized by a reduction in distal pain and/or observation of the centralization phenomenon with the application of repeated or sustained end-range loading strategies to the spine that remain better after assessment. Centralization is defined as a progressive change in pain from a more distal location to a more proximal location that remains better after applying repeated or sustained end-range movement to the spine… hallmark characteristic of the McKenzie derangement classification.”

There is no doubt that a directional preference correlates with great outcomes. There is no doubt that centralization correlates with great outcomes. The thing that needs to happen is that therapists need to be trained to see these during the initial evaluation. A majority of patients demonstrate a classification utilizing the McKenzie method, based on the research of Stephen May. The derangement classification is the largest classification syndrome based off of Stephen May’s previous research, but there are other syndromes. Typically, it’s the derangement syndrome that the research attempts to study. I see very few articles on the other two syndromes in the mainstream research journals.

  1. “There is some evidence that improvement in size and recruitment of the muscles of the spine, including the transverse abdominis, is associated with improved function in the short-term when patients with low back pain receive motor control exercises compared to general exercise or spinal manipulation. However, increases in transvere abdominis and lumbar multifidus thickness using real time ultrasound have also been observed immediately and one week following spinal manipulation in people with low back pain, suggesting that increases in transverse abdominal recruitment may not be specific to motor control exercises.”

OK, a muscles ability to contract is not dependent on its side. A muscle’s ability to contract is based off of that muscle’s ability to receive the nervous system input from the central nervous system. Should there be something that allows for better neural activity, we expect to see an increase in muscle contraction and possibly an increase in muscle size. This is important because we may not have to train a muscle in the traditional sense in order to making muscle contract better.

  1. “The McKenzie method was prescribed according to the principles described by McKenzie and May… Delivered by two therapists who had obtained the level of credentialed therapist from the McKenzie Institute International… Mechanical therapy, including patient and therapist generated forces utilizing repeated or sustained and range loading strategies in loaded or unloaded postures, according to the patient’s directional preference..that guided by symptom response. The aim was to reduce, centralize, and abolish peripheral symptoms… Once symptoms centralize, any movement loss was then treated with repeated and range movements in the direction of movement loss… Received a copy of treat your own back to supplement treatment and self-management.”

The patients included in the study were all patients of the derangement syndrome. When assessing a patient utilizing the McKenzie method, we are attempting to classify the patient into one of three syndromes. This has a high reliability when performed by therapists that are highly trained. The hallmarks of the derangement syndrome is centralization, this occurs when symptoms move from a segment far away from the spine towards the spine. The symptoms in the furthest position from the spine have to decrease or abolish. This is accompanied by the directional preference. A directional preference is as stated, when we move you in a specific direction…your body prefers that. Your body tells us it prefers that direction by centralizing symptoms, improving range of motion, improve strength, or improving other neurological tests such as reflexes and dural tension testing. One can also have a directional preference in the absence of centralization, as extremities also demonstrate directional preferences.

  1. “Initially, promotion of independent contraction of the deep stabilizing muscles, such as the TrA and multifidus, was facilitated by pelvic floor contraction…Objectively, skill mastery of TrA recruitment was measured by palpation and visual assessment for a reduction of overactivity of the superficial trunk muscles…practice daily…attend the physical therapy clinic twice a week for the first 4 weeks and once per week for the remaining 4 weeks”

This is beat into students during PT school…understanding the impact of performing TrA contractions on low back pain. The problem with this theory is that the research is scant on cause and effect. We know that patients with low back pain have smaller multifidi and TrA muscles, but we can’t say “chicken or the egg” yet. We also can’t say if the back pain caused the smaller muscle or if the muscle was smaller and then it caused back pain. More research needs to take place. The topic of centralization and directional preference was briefly touched upon while I was in PT school and the topic of TrA was hammered into us. Now it appears that centralization and directional preference are being taught more in PT schools based on the students that I get as a clinical instructor.

  1. “Participants allocated to the McKenzie method group attended an average of 5.4 +- 2.5 treatment sessions over an average of 38.6+-18.8 treatment days, while participants in the motor control group attended an average of 6.5+-2.7 treatment sessions over 47.3+-22.7 treatment days”

This doesn’t look like a huge difference, but this indicates that those being treated by a MDT credentialed therapist, one less session was required. Think about this again. Each session is performed at a cost to insurance companies (read Medicare) of about $100. At this point, each patient would save $100 to insurance companies when seen by a credentialed MDT therapist. This, over the long term, has dramatic effects on the total cost of spending in the US.

  1. “…no statistically significant effect for treatment group for muscle thickness…at an 8-week follow-up in a population of people reporting chronic LBP classified with a directional preference. Global perceived improvement was the only secondary outcome that demonstrated a significant between-group difference, which favored the McKenzie method”

Let me say this slowly. Using a directional preference based exercise provides the same result as actually training a specific muscle in terms of muscle size! This is huge! We all are taught that to make a muscle bigger (hypertrophy) requires up to 6 weeks of performing an exercise in order to specifically improve a muscles size. This indicates that a muscle’s size can increase without any direct exercises to improve a muscle’s size.

The final piece of this is that those treated with MDT based principles actually felt better than those receiving motor control exercises (read this as core stabilization).

You walk into any clinic in America (aside from those that are doing MDT) and you will see bridges, bird-dogs, pull your belly into your spine exercises, and of course the traditional hot pack and e-stim. These types of treatments may not be the best. Ask your therapist how your back pain is classified. If they can’t give you a straight, honest, and well reasoned answer…FIND A NEW THERAPIST!

  1. I am bolding this, because it is important to read straight from the article. There will be no explanation needed.

“Results from our study suggest that in patients with a directional preference, receiving exercises matched to their directional preference is likely to produce a greater sense of improvement than receiving motor control exercises.”

Excerpts taken from:

Halliday MH, Pappas E, Hancock MJ, et al. A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People with Chronic Low Back Pain and a Directional Preference. J Orthop Sports Phys Ther.2016;46(7):514-522.

Mission Statement

My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations.   I choose to be a leader of example, and not words, all the while reducing negativity in my life.

I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment.

I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

 

 

centralization and the correlation to discogenic pain

Critical Appraisal for a Reference-Standard Validity Study

 

P: For patients with chronic low back pain, with varying levels of distress,

I: can the centralization phenomenon

C: as compared to discography results

O: provide diagnostic power for discogenic pain

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with keyword terms “low back pain and centralization and specificity and sensitivity”.   44 citations were found between the years 2004 and 2014.

 

Date of Search: January 21,2014

Re-evaluation date: January 25, 2014

 

Citation:

Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.

 

Summary:

This validation study has two purposes. The first is to investigate the predictive value of the centralization phenomenon (CP) in relation to provocation discography, which is the only reference standard available for discogenic pain. The second is to investigate the role of distress and disability with regards to the predictive value of the centralization phenomenon in relation to provocation discography.

 

The inclusion criteria were patients with persistent low back pain (LBP), with or without lower extremity (LE) symptoms, whom were referred to a private radiology practice. Patients were excluded for the following reasons: a normal magnetic resonance imaging (MRI) assessment, severe degeneration associated with spondylolisthesis, and if the discography was contraindicated or a referral ruled out discography. The patients that were included were assessed consecutively.

 

Prior to the evaluation by a physical therapist, the patient completed a visual analog scale (VAS) for pain and the Roland-Morris Disability Questionnaire (RMDQ). The Zung Depression Index (ZDI), Modified Somatic Perception Questionnaire (MSPQ) and the Distress Risk Assessment Method (DRAM) were also completed prior to the physical therapy (PT) evaluation. The evaluation was performed prior to the discography and the physician performing the discography was blinded to the therapist’s results. The therapist was blinded to the results of the subjective outcome measures.

 

The physical evaluation consisted of a McKenzie evaluation. The exam required 30-60 minutes and also included sacro-iliac joint (SIJ) provocation tests. Centralization or peripheralization was noted and at this point the examination was terminated.

 

Discography was performed using standard technique and the patient was required to report pain in at least one disc, without pain at an adjacent disc in order to receive a positive test result.

 

One hundred eighteen patients participated in the PT evaluation and discography. One hundred seven patients were included in the initial analysis. Of the 107 patients, 69 received a full PT evaluation, 21 received a partial evaluation and 17 did not receive an evaluation. Of the above, the physical therapist offered an opinion regarding CP for 83 patients.

 

Appraisal:

The authors utilized the only reference standard studied, provocation discography, in order to determine if CP is predictive of discogenic pain. The physician was blinded to the physical therapists’ evaluation and the physical therapist was blinded to the patients subjective outcome measures. Not all patients received both the PT evaluation and discography.

 

The confidence interval was 95%. For non-distressed patients, the following statistical measures were calculated: sensitivity of 37%, specificity of 100%, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were incalculable due to a specificity of 100%. For distressed patients, the following statistical measures were calculated: sensitivity of 45%, specificity of 89%, LR+ of 4.1, and LR- of 0.61. For not severely disabled patients, the following statistical measures were calculated: sensitivity of 35%, specificity of 100%, LR+ and LR- are incalculable due to 100% specificity. For severely disabled persons, the following statistical measures were calculated: sensitivity of 46%, specificity of 80%, LR+ of 3.2 and LR- of 0.63

 

Conclusion:

Performing a McKenzie evaluation in order to determine the presence of CP is a good test for determining a positive discography, especially in patients without severe disability or distress. The presence of CP improves the pre-test probability to post-test probability of positive discography from 39% to greater than 75% in patients with severe disability or distress. CP is a strong predictor of positive discography in patients without severe distress or disability.

Why be a mentor?

I have some passions in the profession of physical therapy and the first is to provide the best care to my patients.  The second is to create therapists that will provide the best care to patients, as they indirectly represent me.  I do my best to ensure that PT students that go through me develop the reasoning ability to understand ethical and unethical environments that will challenge their ability to provide that best care to patients.  This profession is very much driven by the almighty dollar and I understand why some students make specific decisions as to which job to take, but as long as that student has weighted the “pro’s” and “cons” of taking a job, I know that I did what was right in teaching my students.  Some students unfortunately never develop that ability to reason past the $$$.  

 

The Oxford dictionary defines mentor as “an experienced and trusted advisor” and “an experienced person in a company, college, or school who trains and counsels new employees or students.” 1 There are published studies that oppose this definition, which will be discussed in detail further in the paper. Other professionals have specific definitions of mentor as follows: “ Mentor is an individual with noted experience and position within the Military Nurse Corps who possesses a genuine interest in guiding the professional and personal development of a less experienced Nurse Corps officer.”2 As a physical therapist, mentoring is a topic of importance for the author.   I started my career as a teacher of biology, secondary education, with the intent to mold current students into future leaders. Because of circumstances, that dream was never to become a reality and I chose a different career path. My first year of clinical practice, I was asked by GSU to be a clinical instructor because of personal characteristics. Holmes3 states that novice clinicians placed in a mentoring role may have difficulty with individual personal development. My boss/mentor at the time believed that I possessed the qualities to overcome this added adversity and after serving as a clinical instructor for the first student, I found that my initial dream could become a reality in this new field. The stresses of mentoring during the initial years

Christiansen et al5 notes that there are two processes for mentor selection: assignment by an institution or selection by the protégé. Others disagree with this statement, in that preceptors are assigned, but mentors are chosen8. It is advised to choose a team of mentors in order to advise on multiple issues, with each mentor having a specialty6. In the end, one should choose a mentor “who exemplifies traits and skills that you want to adopt”6.

As a mentor, it is rewarding to observe students and clinicians that choose me as a mentor when these individuals apply the information garnered from the relationship in order to treat a patient whom previously the clinician would not have the knowledge or experience to treat. This is consistent with Wainwright et al4, in which the following is stated: 1. clinical decision-making is advanced through clinical education, 2. positive mentoring enhances clinical practice skills, 3. Experienced clinicians inevitably become mentors to novice clinicians. Christiansen et al5 and Holmes et al3 also relate mentoring to the advancement of clinical skills.

Attributes and roles of a mentor are widely published in the research as demonstrated in the following table:

Characteristics Roles
Experienced4,8 Coach6,10
Content knowledge5,6 Advisor1,6,9
Communication skills5,8,9 Counselor1,6,10
Personal integrity5,6 Confidant6
Self-reflection5  
Systems-based learning5  
Willingness to teach5  
Intellectual humility5  
Internal locus of control5  
Empathy8  
Caring8  
Unbiased6,9  
Committed6  
Maintains confidentiality6  
Patience6  

 

As stated previously, a mentor is an advisor…who counsels new employees or students1. Christiansen et al5 states, “Mentoring is not supervising, advising, career counseling, shadowing or coaching. Mentoring is workplace learning and must occur within that environment.” Although the previous statement relays that a mentor must work in the same environment as the mentee, Liu and Ansbacher6 state that long-distance mentoring can be successful through e-mail, phone conferencing or meeting at annual conferences. Based on the aforementioned articles, the act of mentoring appears subjective in nature, as varying authors have different opinions on both the definition and act of mentoring.

“Mentoring requires dedication to the process, which includes substantial investments of time, energy, and resources-physical, emotional and intellectual.”3

As a clinical instructor and mentor to other Mechanical Diagnosis and Therapy (MDT) trained therapists, this statement is accurate. When I was a new professional (< 5 years of experience), I was consistently studying the concepts of MDT, hierarchy of knowledge principles and coursework for clinical instructors. This studying was not without cost. I sacrificed time from family, friends and life experiences in order to work towards that initial dream. Being a mentor also poses a challenge of finding a mentor4. The mentors that I chose are from around the country, and I am only able to meet with them at large spine conferences. As a clinical instructor, I am aware of the bias that is inherent when a relationship is created and established with a mentee and try not to provide preferential treatment for my students7.

The American Physical Therapy Association (APTA) does not define a mentor, but establishes the roles for the mentor and protégé as follows11:

MENTOR

  1. Acclimate the early-career protégé into the culture and the value of PT12
  2. Help the ECP understand the core values of PT and the role of each PT and PTA to support the practice mission of PT
  3. Be open to working as a mentor
  4. Create a collegial atmosphere that provides responsiveness and respect for the ECP
  5. Seek training and education to further skills in mentoring

PROTÉGÉ

  1. Identify knowledge and skill gaps
  2. Establish career goals for life-long learning, both short and long term.
  3. Identify specific experiential opportunities
  4. Identify potential mentors, both junior and senior, who have compatible interests.

During the literature review for this paper, there was only one article that formalized a mentor program. Burritt et al13 studied the outcomes of removing experienced nurses from clinical practice in order to work as a mentor for novice nurses. “The prevalence of stage 2 or greater nosocomial pressure ulcers improved by 38%, which was significantly lower in the post implementation phase. A 47% reduction in the number of adverse events that comprise the composite measure of failure to rescue was also noted to be significant.” Tactics such as this may also influence retention rates of nurses8.

CONCLUSION

To conclude, Holmes et al3 sums it up in a concise statement, “Rejoice in the successes of your mentee, these triumphs can only enhance your own standing.” The author personally chooses to be a mentor for those with less experience, in order to assist those with the characteristics needed to become a successful mentor. My dream of creating future leaders is now reality as my protégés are now becoming mentors.

Bibliography

  1. Mentor. In Oxford dictionary online. Retrieved from http://www.oxforddictionaries.com/us/definition/american_english/mentor.
  2. Blankenbaker SE. Mentor Training in a Military Nurse Corps. Journal for Nurses in Staff Development. 2005;21(3):120-125.
  3. Holmes DR, Hodgson PK, Simari RD, Nishimura RA. Mentoring: Making the Transition from Mentee to Mentor. Circulation. 2010;121:336-34.
  4. Wainwright SF, Shehpard F, Harman LB, Stephens J. Factors That Influence the Clinical Decidion Making of Novice and Experienced Physical Therapists. PTJ. 2011;91:87-101.
  5. Christensen N, Gerber P, Jensen G, et al. (2014). American Board of Physical Therapy Residency and Fellowship Education: Mentoring Resource Manual. Accessed from: www.abptrfe.org
  6. Liu JR, Ansbacher R. Assembling the Optimal Mentor Team. Obstetrical and Gynecological Survey. 2008;63(4)

7.Coulson CC, Kunselman AR, Cain J, Legro RS. Graduate Education: The Mentor Effect in Student Evaluation. Obstet Gynecol. 2000;95:619-622.

  1. Martin CA. Across the Generations: It takes a village to raise a nurse. Nursing Critical Care. 2007;2(3):45-49.
  2. Ansbacher R. A Guest Editorial: The Mentor-Mentee Relationship. Obstetrical and Gynecological Survey. 2003;58(8):505-506.
  3. Hurst SM, Kplin-Baucum S. Innovative Solution Mentor Program: Evaluation, Change and Challenges. Dimens Crit Care Nurs. 2005;24(6):273-274.
  4. American Physical Therapy Association. (2012). Best Practice for Mentoring Early-Career Proteges: HOD P06-12-16-05. Retrieved from: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Professional_Development/BestPracticesMentoringEarlyCareerProteges.pdf.
  5. Gardner EA, Schmidt CK. Implementing a Leadership Course and Mentor Model for Students in the National Student Nurses’ Association. Nurse Educator. 2007;32(4):178-182.
  6. Burritt J, Wallace P, Steckel C, Hunter A. Achieving Quality and Fiscal Outcomes in Patient Care: The Clinical Mentor Care Delivery Model. JONA. 207;37(12):558-563.

Not all back pain has a definitive cause

“Findings such as disk height loss and disc bulges are coming in individuals without low back pain.”

Disc bulges, degenerative joint disease, spinal stenosis, do you all a result of living in this world. We have gravity acting a force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. we can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you exactly what causes your back pain.

“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified Depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”

What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patients physical complaints.

“Our results indicate that depression is a strong predictor of who will subsequently reports low back pain then baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times is likely to have back pain compared with those who do not report depression.”

There is obviously a psycho social component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.

“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and route contact may also be risk factors for future low back pain.”

In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.

The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Excerpts from:

Jarvik JG, Haegerty PJ, Boyko EJ. Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;30(13):1541-1548.

Brother my Brother

Today’s blog is very different from any of those written before. This is an insight into my life, into my thought process, into my experiences, into those things that made me who I am. I started this blog to teach people about healthcare, but there is so many more things that people can learn from my experiences. I dictate today’s blog on my way to the cemetery. It’s a little bit more emotional than anything that I would typically write. 
 Life is precious. My brother is a fucking idiot, in 2008 he overdosed. He never really saw anything outside of Joliet Illinois. I want to live until I die. There is too much to see and too much to live for in this life. After eight years, I still think of everything that he missed out on. He missed out on having a family. My family is the greatest thing that ever happened to me. I would be my fathers son, I would be content to stay at home and work hard and live my life in that fashion. My wife loves to travel and loves try new things. If it wasn’t for her I would’ve never traveled to Europe, I may have never made to Alaska. If it wasn’t for my daughter, I wouldn’t slow down and slide down the big slide. I probably wouldn’t go to another waterpark, I probably wouldn’t climb in the tunnels at Odyssey fun world. My brother missed out on a lot, when I go visit cemetery it just my heart.. Life is precious. For those going through difficult times, Know that life is precious. There are people that love you and people that will miss you if you’re gone. I miss my brother frequently. Life goes on, and life will go on without you. I hate to say that because it sounds harsh but it will. I am happy, and unfortunately he’s not here to see that. 

At what age does dreams die? I don’t know that answer. At what age do we throw in the towel? At what age do we give up? I don’t know what was going through my brothers head those last days And it kills me eight years later. 
In memory of Michael Anderson. I miss you brother

Lead from the front

“When an organization or an individual experiences success in any manner, it may be difficult to alter the path we have been following.”
I could see this being true, but only for people who have that one success as the end goal. Some people aspire for more, some people aspire for better.
“Successful leadership is not just about the leader; it is about the team. Leaders must constantly find new solutions to the problems.”
This sounds like a quote from Phil Jackson. The team is the number one priority and the star athlete has to figure out how to fit into the team. The leader’s job is to ensure that the team can play together, and play at a high-level together. In order for leaders to constantly find new solutions to the problems, the leaders have to have an open point of view in order to see the problems. I have seen many who simply stick their head in the sand and ignore that the problem exists. In order to fix problems though, things will have to change. It’s obvious that should there be no change there will be no solution to the problem. This change will cause stress to the dynamics of the team, and the team must be able to handle that stress effectively and efficiently in order to maintain that high level of productivity.
“But leaders should not be afraid to erase the chalkboard sometimes and start from scratch”
Every system has flaws. Every system can be improved. Sometimes the flaws in the system are fatal. When this occurs the entire system needs to be scratched. I don’t know if a leader though can see this. These types of issues need the 20,000 foot view in order to see the big picture. When one is so close to the problem that they are in the problem, I do not believe that that person can actually see the problem.
Excerpts taken from:

Gregersen H. Leadership: When was the last time you asked, “Why are we doing it this way?”. IMPACT. June 2016:57.

Lean Management Theory

Lean Management Theory

 

  1. “The concept of 5S is just one of several key elements of the lean principle, which is designed to improve efficiency in the workplace while promoting organization and cleanliness.”

 

I can remember my teenage years. I started working at the age of 12 as a ranch hand and continued to work through this day. During those years, I worked as much as I was needed, because $20 was more attractive than anything else that I was doing with my time. My room was a disaster. I had trails in order to go from the door to the bed and another trail to get to the dresser. Fast forward 7 years, I was working at Sam’s Club 8298 during the overnight shift. I was nicknamed “The Tornado”. I could stock off a pallet faster than anyone else in the club. At times, they had to have someone come behind me to clean up after me, because it was faster to let me do all of the heavy work and pay someone else to do the “easy” stuff”. Continue to fast forward to one year ago, I was the most productive therapist in the clinic, priding myself in how many patients I could treat in a day, and still get good results of course. Fast forward to today, I realize that none of that matters. If I can teach people to do what I do, then I can help to create systems, which is now more interesting to me than simply stocking shelves, feeding horses, or treating patients. Don’t get me wrong, I enjoy treating patients, but I can only effect one person at a time. That is not as productive as creating systems to treat 10’s of patients at once, with the same treatment philosophy and outcomes. I now realize the importance of cleaning up my room, 36 years later.

 

  1. “The 5 “S’s” in Japanese are Seiri (tininess), Seiton (orderliness), Seiso (cleanliness), Seiketsu (standardization), and Shitsuke (discipline)”

 

Am I the only one imagining Myagi-son saying these words with emphasis? It sounds do formal and warrior-like.

 

  1. “In its simplest form it is designed to keep the workplace safe and organized without regard to size or pace”

 

When I worked at Sam’s, I could do aisles per night without ever tiring. Now, I left all of the cleaning until the end of the night (unless of course they had someone come over and clean up after me). What was the problem with waiting until the end of the shift to clean? I made everyone else’s jobs harder by taking up so much space that it was hard to get a forklift down my aisle during the shift. It was very productive for me, but I slowed down the entire team. It took years to figure this out, but my zealousness of productivity may be a detriment to the team.

 

  1. “The goal of the 5S is to remove waste, both actual and conceptual, by eliminating excess inventory and out-of-stock supplies, and reducing wasted time searching for, getting to , and waiting for supplies”

 

This is but one example. Think of the 20,000 foot view of eliminating waste (both in terms of stuff not used, and time spent on stuff not needed). I try to listen to multiple podcasts per day, and this concept is spoken of in many shows such as EntreLeadership, Barbell business, Tim Ferriss, and The School of Greatness.

 

  1. “Keep only what is necessary”

 

This is hard to do, especially when thinking of “what if”. I have like 8 pairs of jeans, but will only wear the jeans that don’t restrict my squat, namely 2 pairs. This means that at the end of my closet, I have 6 pairs of jeans that haven’t been worn in a long time, just in case I need to wear a third pair of jeans. The clutter in the closet would be removed if I just donated or sold the other pairs of jeans. Parting with any thing that we “own” is hard because we can always create scenarios in which those “things” are needed. Unfortunately, that same scenario never plays out in real life.

 

  1. “…identify, organize, and arrange everything in the work area, so that items can be efficiently and effectively retrieved…Everything should have a place and a purpose”

 

I suck at this step. Good story. I am on a team that is very close in terms of trust and partnership at work. There is a long running joke that I am Oscar and my supervisor is Felix. Hang out with us enough and it becomes obvious to those that understand the metaphor. I am learning that I need to become more like Felix in order to improve professionally. (For those that don’t understand the metaphor, go look up the Odd Couple…and nothing that was produced after 1990).

 

  1. “Once you have everything sorted and set, it is important to keep it that way…requires regular cleaning”

 

Because I suck at the previous step, this is also not a strong point for me. I know where I want to keep things, but for some unknown reason my way is not always the best way for everyone else. I struggle with the regular cleaning step. When I worked at PT and Spine, Bill was a stickler for standard operating procedures (SOPs). It wasn’t written, but he had a way that he like the clinic cleaned every night before locking the door. There was a proper way to open and close the clinic. Because I don’t have that type of standard at the place I work now, it makes it difficult to put everything in its place. I know that it sounds corny to think that there should be a standard operating procedure for the little things, but go back and listen to barbell business’ SOPs episode and it will all make sense.

 

  1. “Develop written structures and standards that will support the new practices and turn them into habits”

 

I am hard headed at some things. When it comes to organization, I have the ability to learn it, but I am a slow learner. I can spout off statistics on back pain, I can assess/treat darn near anything coming into the door, but performing organizations skills and all of a sudden…DUH? In Bill’s clinic, I was there for 2 years and by the time I left, I was able to leave the clinic in the exact way that I found it.

 

Funny story though: My dad is a Vietnam Vet (101st Airborne medic) and he could tell if something in his room moved while he was at work. Needless to say, if I wanted to be discreet, I could be. Unfortunately, this same discreetness doesn’t carry over to other situations.

 

  1. “Standardize is one of the harder steps in 5s as it calls for changing habits”

 

If I were a clinic owner, I would only hire new graduates that performed a clinical with me. It just seems much easier to teach what I find works best than to unteach stuff that I don’t like or research doesn’t support and then teach what I do prefer. This being said, being in a clinic with people who have much “experience” makes creating new standards difficult. Clinicians can be set in their ways and change can be scary. It is less scary for those that don’t know any better.

 

Excerpts taken from:

Spradling SC. Practice Management Systems: Add value to your practice by “5S’ing”. Impact. June 2016:31-32.